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-•ear. I? FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT - --- -------------------- ----------------------------- Permit No. . --------------- �--,.----..(Complefie-in Triplicate) .. ��-••-�--•------ • = ------- - gg - Z3 Date Issued This Permit Expires 1 Year from Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION ----------- ------ ,u-& -- �, �--------CENSUS TRACT ---------------•--•-•----- Owner's Name ------- ------ ---------------- -------------------------------- -Phone _ -ltd a ----------- Address ------ -------rd>7.UV---------5-'------ r�e — ----------------------------------- city fiDU l-------- -•-•---- I • I y- ^�---------- -----License # 21 A! Phone Contractor's Name ---i_______."________ _ _ ____ Installation will serve: Residence [Apartment House[:] Commercial [ Trailer Court ;❑ Motel ❑Other --------------------------------------- ---- Number of living units:_----- Number of bedrooms ---3-----Garbage- Grinder _*_U_---- Lot-Size -1110,-i- -------------------- I Water Supply: Public;System and name -------------------------------------------------------------- --------------------------------------- --------Private Character of soil to a depth of 3 feet: Sand y Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .E] Hardpan ❑ Adobe '❑ Fill Material ------------ If yes,type ".-___---_ __.__________ (Plot plan, showing size of at, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATIIONI:� p seepage pit permitted if public sewer is available within 200 feet,) I (No septic tank or I ,. -.- PACKAGE � � y PACKAGE TREATMENT { ] SEPTIC TANK�Vq Size------ "y-5_-1--�------------------------ Liquid Depth"------ ---------- Capacity --------- Ca acct / ____[�-_ No. Compartments _.,_.2------------- I -_- _. -. p Ya�J Type r� �cMa#erial '` Distance to nearest: Well -------/_1_t)....................Foundation -------/.v._{__._._ Prop. Line ----Jv__.= _ ____ C I G LEACHING LINE [ ] No, of Lines - _.__�______ Length of..b�each line__= Total Length f -------0 _ } b' Box ..__�___-__ Type Filter Material _//6.X Depth Filter Material ..__ ----------------------------_- t Distance to nearest: Well _.__ �L?------------ Foundation ----� ___(..._.___ Property Line, ._____._.__. Diameter ____----_--_"__- Number __/44-Rock._ Filled Yes No I SEEPA PIT [� F DepthI ------ F � I Wciter'Table Depth --------------------- Rock Size /?r` --- I Distance to-nearest: Well ______ Q__.___ _______________Foundation _. .___ -___ Prop. Line.: ------._________- REPAIR/ADDITION(Prev. Sanitation Permit# ________ ___________________________________ Date --__---_____._______"____________} I Septic Tank (Specify Requirements) ---------------------------------------------------------------- I-- ------ P Disposal Field (Specify Requirerhents) ------------------------------------------------------------------ ------'------------- ------------ ------------------- f: -------- - ------- ----------------Ll-------------- --- ---------------------------- )Draw existing andrequired addition on reverse'side) 1 I hereby certify that'11 have. prepared this application"s and`tKtaf-the worV,will be done in accordance with San Joaquin County Ordinances, State Laws, pfd Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: - ) "I certify that in the performance of the work for which thV permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation Iaws..of California." Signed -----------------------I-------------------------------- ^-------------------------------------- Owner —` By j E ` -------------- Title ----------------------- -------------- ---- ----------------- (If other than owner) y. I F DEPARTMEN USE 'ONLY APPLICATION ACCEPTED BY - --------------------------------- -- ---------------------------------- DATE l'�� 3---- BUILDING PERMIT ISSUED -- ---------------------------------------------------- --- -----------------------------;--------------DATE -------------•----------------------------- ADDITIONAL COMMENTS --------------------------------------------------------------------------------------------------------- € I ------------ ------------------------------------------------------------------------ ------------------- # ------------------- ---- ---------------------Date-_-- y 7 FinalInspection by ------ - - -- - ----- - - -------------- ----------------- --------------------------- - € SA_N J.OAQU.I.'—LOCAL_HEALT.H_DISTRICT y , y �; E. H.1 1•,-'68,Rev, 5M 777